ORAL AND MAXILLOFACIAL BIOPSIES: A 6-year audit of histopathology forms

Abstract

BACKGROUND: The request for histopathology report is usually through completion of a form designed in a questionnaire pattern. Failure to provide adequate and relevant information often result in laboratory or diagnostic errors. Mismanagement of the patient therefore becomes the final outcome. This study evaluates the level of completion of forms submitted to an Oral & maxillofacial pathology service in a tertiary hospital in Nigeria

METHODS: The histopathology request forms that accompanied all oral and maxillofacial biopsies, histopathology reports and patients’ case files over a 6-year period (2012-2018) were retrieved from the archives and evaluated for level of completion. A form was considered “satisfactorily completed” when all 14 assessed questions had responses, and “unsatisfactorily completed” if a response is missing. Data was analyzed using SPSS software, version 20.

RESULTS: A total of 429 request forms were evaluated. Only 76 (17.7 %) forms were satisfactorily completed, while 353 (82.3 %) omitted one or more requested information. High completion rates were obtained for patients' names (100%); gender (n=417, 97.2 %); clinical details (n=416, 97.0 %); and case file number (n=403,   93.9%). Omitted information were observed for the following questions: Clinician’s contact phone (n=353, 82.3%); imaging / radiographic report (n=126, 29.4%); and forms without signature of clinicians (n=24, 5.6%). Consultants only signed 3 (0.7%) of the request forms.

CONCLUSION: There is a low rate of satisfactorily completed histopathology request forms. The poor supervision by consultants, and delegation to subordinates, may be responsible.